Journal of Personality Assessment, 94(5), 522–532, 2012

Copyright
C Taylor & Francis Group, LLC

ISSN: 0022-3891 print / 1532-7752 online
DOI: 10.1080/00223891.2012.700664

ARTICLES

Assessing the Level of Structural Integration Using

Operationalized Psychodynamic Diagnosis (OPD):
Implications for DSM–5
JOHANNES ZIMMERMANN,1 JOHANNES C. EHRENTHAL,2 MANFRED CIERPKA,3 HENNING SCHAUENBURG,2
STEPHAN DOERING,4 AND CORD BENECKE1
1
Department of Psychology, University of Kassel, Germany
2
Department for General Internal Medicine and Psychosomatics, University of Heidelberg, Germany
3
Institute for Psychosomatic Cooperation Research and Family Therapy, University of Heidelberg, Germany
4
Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Austria

A key ingredient in the current proposal of the DSM–5 Work Group on Personality and Personality Disorders is the assessment of overall severity
of impairment in personality functioning: the Levels of Personality Functioning Scale (LPFS). The aim of this article is to contribute a conceptual
and empirical discussion of the LPFS from the perspective of the Operationalized Psychodynamic Diagnosis (OPD) system (OPD Task Force,
2008). First, we introduce the OPD Levels of Structural Integration Axis (OPD–LSIA), a measure of individual differences in severity of personality
dysfunction that is rooted in psychodynamic theory. We show that the OPD–LSIA is reliable, valid, and highly associated with observer ratings
of personality disorders. In the second part, we present results from an OPD expert consensus study exploring potential limitations of the current
LPFS item set from the perspective of the OPD–LSIA. We conclude with highlighting implications for future revisions of the DSM–5 proposal.

The classifications of personality disorder (PD) in the Diagnos- categorical model might help to overcome the limitations of
tic and Statistical Manual of Mental Disorders (4th ed., revised DSM–IV already mentioned.
[DSM–IV–TR]; American Psychiatric Association, 2000) and The proposals of the DSM–5 Work Group have been discussed
the International Classification of Diseases (ICD–10; World in various special issues and journal articles (e.g., Bornstein,
Health Organization, 1992) are currently undergoing major re- 2011; Leising & Zimmermann, 2011; Livesley, 2012; Pilkonis,
visions (Skodol, Clark, et al., 2011; Tyrer et al., 2011). The main Hallquist, Morse, & Stepp, 2011; Pincus, 2011; Shedler et al.,
goal of this process is to solve various shortcomings that narrow 2010; Widiger, 2011). This debate has primarily focused on
the quality of today’s PD sections in the DSM–IV and ICD–10, whether and which PD types, traits, or both should be included
such as excessive overlap between diagnostic categories, failure in the new system. By contrast, the proposed Levels of Person-
to acknowledge the dimensional nature of personality pathology, ality Functioning Scale (LPFS) seems much less controversial.
and little empirical support (Clark, 2007; Livesley, 1998; Westen For example, even PD experts who were rather critical of the
& Shedler, 1999; Widiger & Trull, 2007). Since February 2010, DSM–5 proposal praised the LPFS as one of its most valuable
the DSM–5 Work Group on Personality and Personality Dis- and useful features (e.g., Livesley, 2012; Shedler et al., 2010).
orders has published proposals for the PD section in DSM–5 Moreover, a rating of overall severity of personality pathology
(see www.dsm5.org). The common denominator of these pro- will be a key ingredient in the PD section of ICD–11 as well
posals is a stepwise rating procedure including the assessment (Tyrer et al., 2011). Thus, there seems to be a relatively broad
of (a) the overall severity of impairment in personality func- consensus that a dimensional rating of the severity of personality
tioning, (b) the degree to which individual personality problems dysfunction is central for the future assessment of PD. Further
resemble prototypical configurations, and (c) the presence of studies are needed, however, to unravel the commonalities and
pathological personality traits and trait facets (Bender, Morey, & differences of various existing measures of PD severity (Craw-
Skodol, 2011; Krueger et al., 2011; Morey et al., 2011; Skodol, ford, Koldobsky, Mulder, & Tyrer, 2011), including the current
2012; Skodol, Bender, et al., 2011; Skodol, Clark, et al., 2011). LPFS item set. This would complement the official DSM–5 Field
The DSM–5 Work Group suggests that this hybrid dimensional- Trials and support the DSM–5 Work Group in calibrating and
refining the LPFS (Skodol, 2012).
The aim of this article is to present such a study. Specifically,
we present a conceptual and empirical discussion of the LPFS
Received February 27, 2012; Revised April 19, 2012. from the perspective of the Operationalized Psychodynamic
Address correspondence to Johannes Zimmermann, Department of Psychol- Diagnosis (OPD) system (OPD Task Force, 2001, 2008; for a
ogy, University of Kassel, Hollaendische Str. 36–38, 34127 Kassel, Germany; related conceptual discussion, see Bernardi, 2010). This seems
Email: [email protected] reasonable because the OPD system provides a highly similar
522
LEVEL OF STRUCTURAL INTEGRATION 523

scale, the Levels of Structural Integration Axis (LSIA), which ally, the fact that disturbances in self–other representations and
has successfully been used in clinical research and practice self- and emotion-regulation mechanisms make up the largest
for more than 15 years. Drawing on the OPD–LSIA could part of the LPFS criteria highlights the influence of contempo-
contribute to the refinement of the LPFS in two distinct ways: rary psychodynamic (Kernberg & Caligor, 2005), attachment
First, showing that clinicians can reliably apply a highly similar (Meyer & Pilkonis, 2005), and interpersonal (Horowitz, 2004)
scale to clinical interview material strengthens the empirical theories of personality pathology. Pincus (2011) even noted that
base of the proposed LPFS. This seems especially needed as the LPFS represents “the return of theory” (p. 44) into a formerly
a number of key studies on the OPD–LSIA are available only atheoretical diagnostic system. One of the most influential the-
in German, probably keeping members of the DSM–5 Work oretical concepts within the development of the LPFS might
Group from considering the OPD–LSIA in their review of have been the psychodynamic concept of personality structure
clinician-rated measures of personality dysfunction (Bender (Kernberg & Caligor, 2005; Rudolf, 2002; Wallerstein, 1991;
et al., 2011). Consequently, after recapitulating the proposed Westen, Gabbard, & Blagov, 2006). Personality structure refers
LPFS, the first part of this article introduces the OPD–LSIA, to the dynamic interplay of repetitively activated psychological
outlines the rating requirements and procedures, and summa- processes that normally serve adaptive functions but can become
rizes existing empirical evidence on reliability, validity, and dysfunctional (Westen et al., 2006). Current conceptualizations
associations with PDs. Second, the OPD–LSIA could serve as of personality structure cover various functional domains, such
a standard of comparison for assessing the comprehensiveness as affective, cognitive, and self-regulatory resources, quality of
of both the severity dimension and the content domains of the self–other representations, and the capacity to get involved and
LPFS. Accordingly, we present an OPD expert consensus study to maintain meaningful relationships. Moreover, they converge
empirically delineating the commonalities and differences of on the notion that the degree of disturbance in functioning can
the two measures. Our findings might be helpful in detecting be differentiated along several prototypical levels. Obviously,
potential limitations of the current LPFS item set, and thus could both aspects are central to the LPFS.
directly contribute to future revisions of the DSM–5 proposal. Methodologically, the relevance of the psychodynamic con-
cept of personality structure for the LPFS is especially apparent
LEVELS OF PERSONALITY FUNCTIONING SCALE in a recent publication by members of the DSM–5 Work Group
According to the LPFS, the severity of personality pathology (Bender et al., 2011). To justify and streamline the first LPFS
is defined by the degree of disturbance in self and interpersonal proposal, Bender et al. (2011) presented a review of clinician-
functioning. More specifically, the DSM–5 Work Group pro- rated measures that could inform the future DSM–5 revision pro-
poses that the domains of identity, self-direction, empathy, and cess. They established several methodological criteria: Instru-
intimacy are most central for personality functioning. Identity ments should (a) contain salient mental functioning dimensions;
captures the experience of oneself as a unique person, the stabil- (b) have a self–other focus; (c) have been employed in studies
ity of self-esteem and accuracy of self-appraisal, and the ability with general clinical samples, personality-disordered samples,
to regulate a range of emotional experience. Self-direction cap- or both; (d) feature concepts useful to a broad range of clini-
tures the pursuit of coherent and meaningful goals, the utiliza- cians; (e) be applicable to rating clinical interview material; and
tion of constructive and prosocial internal standards of behavior, (f) have published psychometric data on relevant domains of
and the ability to self-reflect in a productive manner. Empathy functioning. Applying these criteria, Bender et al. identified five
captures the comprehension and appreciation of others’ experi- instruments, which are all rooted in psychodynamic or psycho-
ences and motivations, the tolerance of different perspectives, analytic thinking: the Quality of Object Relations Scale (QORS;
and the understanding of the effects of one’s own behavior on Azim, Piper, Segal, Nixon, & Duncan, 1991), the Personality
others. Intimacy captures the depth and duration of positive Organization Diagnostic Form (PODF; Gamache et al., 2009),
connections with others, the desire and capacity for closeness, the Object Relations Inventory (ORI; Blatt, Chevron, Quinlan,
and the mutuality of regard reflected in interpersonal behavior. Schaffer, & Wein, 1992), the Social Cognition and Object Re-
It is proposed that the degree of impairment in these domains lations Scale (SCORS; Westen, Barends, Leigh, Mendel, & Sil-
can be differentiated into five levels, ranging from no (0), to bert, 1990), and the Reflective Functioning Scale (RFS; Fonagy,
mild (1), moderate (2), severe (3), and extreme (4) impairment. Target, Steele, & Steele, 1998). Thus, the recent proposal could
To anchor the domains and levels more precisely, the recent be seen as an attempt to integrate existing measures of personal-
proposal offers three short paragraphs for each domain-level ity structure while maximizing reliability and clinical utility. In
combination, resulting in a list of 60 items. Raters are supposed the following, we show that the OPD–LSIA fulfills the criteria
to read the item descriptions across domains and indicate the of Bender et al. (2011), and thus could play an important role in
level that most closely characterizes a patient’s functioning (see the DSM–5 revision process.
www.dsm5.org).
The rationale for the first version of the LPFS was based LEVELS OF STRUCTURAL INTEGRATION AXIS
mainly on theoretical considerations about the nature of person-
ality functioning (Livesley, 1998; Parker et al., 2002; Skodol, Operationalized Psychodynamic Diagnosis
Clark, et al., 2011). The specific combinations of domains and The OPD–LSIA is part of the OPD, which is a multiaxial
levels of the current version were subsequently developed with diagnostic system with the overall aim of reliably assessing
regard to a review of clinician-rated measures (Bender et al., psychodynamic constructs relevant for treatment planning and
2011) as well as secondary data analyses of two self-report psychotherapy research (OPD Task Force, 2001, 2008). The
measures of personality functioning (Morey et al., 2011). OPD Task Force was founded in 1992 by a group of Ger-
From the perspective of the OPD–LSIA, it seems important man psychoanalysts, specialists in psychosomatic medicine,
to note that psychodynamic concepts and measures played a and psychiatrists with a background in psychotherapy re-
major role in the construction process of the LPFS. Conceptu- search. The goal was to broaden and enrich the descriptive and
524 ZIMMERMANN ET AL.

symptom-oriented classification systems of the ICD and DSM is significantly limited, and internal conflicts are mainly en-
by including psychodynamic dimensions. The first version of acted in interpersonal relationships. The central fear is of being
the diagnostic inventory was published in 1996. Since then, the harmed or destroyed by important others or destructive introjec-
manual has undergone one major revision (i.e., OPD–2), and tions. Disintegration is characterized by the fragmentation and
has been published in several languages (e.g., English, Spanish, psychotic restitution of structure. Consequently, the central fear
Chinese, Italian, Rumanian, Russian, Czech, and Hungarian). relates to the symbiotic merging of the self and objects, resulting
The OPD includes four psychodynamic axes, which comple- in a dissolution of the sense of self.
ment ICD–10 or DSM–IV: Experience of illness and prereq- The standard rating procedure of the OPD–LSIA requires
uisites for treatment (Axis I), Interpersonal relations (Axis II), assessing a person’s level of structural integration with respect
Conflict (Axis III), and Structure (Axis IV). In the following, we to the eight primary dimensions. Each dimension is described
limit our presentation to Axis IV, which constitutes the Levels in a checklist included in the manual, with short paragraphs
of Structural Integration (for detailed descriptions of Axes I–III, for respective combinations of subdimensions and levels (OPD
see OPD Task Force, 2008). Task Force, 2008). The dimensions are rated on 7-point Likert
scales (using main and intermediate levels). In addition to the
Description of Dimensions, Subdimensions, and Levels ratings of the specific structural dimensions, the overall level of
The OPD–LSIA provides an instrument for assessing the structural impairment is also rated. A recent methodological step
availability of fundamental capacities and skills. According to is the development and validation of a self-report questionnaire
the OPD–LSIA, structural functions are linked not only to the based on the OPD–LSIA (Ehrenthal et al., 2012).
inner world of an individual, but also to the external world of so-
cial relationships; that is, to both the self and objects. Personality Rating Requirements
structure is therefore described in terms of four basic functions, A rating of the full OPD system requires a clinical interview
each of which is differentiated with regard to the self and oth- of at least 60 to 90 min, covering the usual range of clinical
ers: perception/cognition of the self and objects, regulation of issues: current and former problems and complaints, prototypi-
the self and relationships, communication with the internal and cal descriptions of the self and others, significant relationships
external world, and attachment to internal and external objects. including parents, siblings, partners, and friends, issues of in-
Each of these eight primary dimensions is specified by means timacy and psychosexual development, and information about
of three subdimensions, which represent specific and clinically childhood experiences (OPD Task Force, 2008). Raters are sup-
meaningful abilities. posed to complete a standard training, applied in three units of
Table 1 gives an overview on the self–other framework of the 60 hr in total. Ten to 15 hr usually focus on the structure axis
OPD–LSIA, including four basic functions, eight primary di- (OPD–LSIA). The training is conducted with the help of video-
mensions, and 24 subdimensions. For example, self-perception taped interviews and case vignettes. To be certified as an OPD
consists of the following three subdimensions: the ability to rater, trainees have to demonstrate the quality of their ratings by
reflect on oneself, to differentiate one’s own emotions, and to sufficient agreement with expert ratings.
maintain and develop a sense of identity. Regulation of rela-
tionships includes the ability to protect relationships from one’s Psychometric Properties
own impulses, to maintain a sense of one’s own interests and
needs and balance them with the interests of others, and to antic- A growing body of research shows that the OPD–LSIA is a
ipate the impact of one’s behavior on significant others. Exter- sufficiently reliable and valid method for assessing personality
nal communication includes the ability to engage in emotionally structure (for reviews, see Cierpka, Grande, Rudolf, von der
meaningful contact, to communicate one’s own emotional states Tann, & Stasch, 2007; Cierpka et al., 2001; Dahlbender,
and be receptive to others’ emotions, and to understand and be
empathic to others’ inner worlds. A more detailed description TABLE 1.—Functions, dimensions, and subdimensions of Levels of Structural
can be found in the OPD manual (OPD Task Force, 2008). Integration Axis.
Individual differences in functioning are conceptualized
along four main levels, ranging from good integration (1), to Self Object
moderate integration (2), low integration (3), and disintegration
Perception/ Self-perception Object perception
(4). These levels represent prototypical amounts of differenti- cognition – Self-reflection – Self–object differentiation
ation and integration of personality processes that are crucial – Affect differentiation – Whole object perception
for adaptively dealing with internal and external demands. An – Identity – Realistic object
individual with good integration is characterized by a relatively perception
autonomous self with enough flexibility as well as stability for Regulation Self-regulation Regulation of relationships
– Affect tolerance – Protecting relationships
tolerating and adequately processing impulses, emotions, and – Impulse control – Balancing interests
conflicts. The central object-related fear is of losing the other’s – Regulation of self-esteem – Anticipation
affection or love. Moderate integration involves restricted regu- Communication Internal communication External communication
latory function and heightened vulnerability for self-destructive – Experiencing affect – Making contact
– Use of fantasies – Communicating affect
and self-devaluative tendencies. Regulatory strategies concern- – Bodily self – Empathy
ing impulses, emotions, and conflicts prototypically follow an Attachment Attachment to internal Attachment to external
overcontrolling mode. The central fear is of losing the (needed) objects objects
others or objects. For individuals with low integration, regula- – Internalization – Capacity for attachment
tory function is usually severely impaired, leading to repetitive – Use of introjects – Accepting help
– Variability of attachment – Detaching from
flooding by intense negative affect and engagement in (self-) patterns relationships
destructive behavior. An understanding of the self and others
LEVEL OF STRUCTURAL INTEGRATION 525

Rudolf, & OPD Task Force, 2006; Rudolf & Doering, 2012; Overbeck, & Grabhorn, 2006; Nitzgen & Brünger, 2000;
Schauenburg & Grande, 2011; W. Schneider, Buchheim, et al., Rudolf, Grande, Oberbracht, & Jakobsen, 1996; G. Schneider,
2002; Zimmermann et al., 2010). In the following, we (a) review Lange, & Heuft, 2002; G. Schneider, Mendler, Heuft, &
studies that assessed the interrater reliability of the OPD–LSIA, Burgmer, 2008; Spitzer, Michels-Lucht, Siebel, & Freyberger,
(b) summarize evidence on the validity of the OPD–LSIA global 2002a, 2002b, 2004; Schauenburg, 2000; Strauß, Hüttmann, &
score, and (c) present a meta-analysis on the association between Schulz, 1997; Thomasius et al., 2001; Uzdawinis et al., 2010).
the OPD–LSIA global score and observer ratings of PDs. In the following, we highlight the most relevant findings.
First, several studies support the convergent validity of
Reliability. Three studies have shown that the OPD–LSIA the OPD–LSIA by showing that it is highly correlated with
is sufficiently reliable when applied by trained and experi- self- and observer reports of personality structure. For ex-
enced clinicians (Benecke et al., 2009; Cierpka et al., 2007; ample, Doering et al. (2012) found a correlation as large as
Cierpka et al., 2001; Doering et al., 2012). Cierpka et al. (2007; rs = .68 between global scores of the OPD–LSIA and the
Cierpka et al., 2001) investigated the interrater reliability of the Structured Interview of Personality Organization (Clarkin,
OPD–LSIA in a study of 269 patients from six psychotherapy Caligor, Stern, & Kernberg, 2004) in a mixed sample of 125
inpatient clinics. Due to variation in the rater conditions across inpatients and outpatients. A reanalysis of the data collected by
clinics, it was possible to examine which conditions led to im- Grütering and Schauenburg (2000) revealed that global scores
proved reliability. The authors used weighted kappa (Cohen, of the OPD–LSIA and the Karolinska Psychodynamic Profile
1968) to assess the correspondence between two raters. When (Weinryb & Rössel, 1991) were significantly correlated as well.
ratings were based on videotaped interviews conducted for di- Müller et al. (2006) showed that a lower level of structural in-
agnostic purposes, the mean weighted kappa value across OPD tegration was significantly associated with deficits in reflective
dimensions was .71. When ratings were based on videotaped in- functioning as measured by the RFS. Moreover, Grande et al.
terviews, but conducted by clinically inexperienced students, the (2002) found that a lower level of structural integration was
mean weighted kappa value was lower (κ = .55). However, the associated with emotional blunting and difficulties relying on
weighted kappa for the global score still reached .70. In a more others as measured by the Scales of Psychological Capacities
recent study, Benecke et al. (2009) had three raters assess 139 in- (Wallerstein, 1991). Benecke et al. (2009) assessed the cor-
dividuals based on videotaped interviews. The sample consisted respondence between the OPD–LSIA and two self-reported
of a diagnostically heterogeneous group of 120 inpatients and measures of personality structure: the Inventory of Personality
19 healthy controls. Rater 1 had participated in standard OPD Organization (IPO; Lenzenweger, Clarkin, Kernberg, &
training and had been supervised in the first period of rating but Foelsch, 2001) and the Borderline Personality Inventory (BPI;
had no clinical experience; Rater 2 and Rater 3 were experienced Leichsenring, 1999). In both cases, the correlations with the
clinicians and OPD trainers. The interrater reliability of the two OPD–LSIA global score were highly significant with rs = .54
experienced raters was high, with a weighted kappa of .83 for for the IPO and rs = .53 for the BPI. These findings are in line
the global score. Weighted kappas between the clinically inex- with unpublished data by Doering et al. (2012) and with an ear-
perienced Rater 1 and the other two raters were lower (κ = .68 lier study by Spitzer et al. (2002b), who also found a significant
and .65). Finally, Doering and colleagues (2012) determined the correlation between the OPD–LSIA global score and the BPI.
interrater reliability among six trained raters. Four raters were Second, as a lower level of structural integration makes
experienced OPD trainers and two raters had just begun their people more vulnerable to experiencing negative psycholog-
clinical work. Each of 125 videotaped OPD interviews of psy- ical outcomes, the OPD–LSIA was expected to be signifi-
chiatric inpatients and outpatients was independently assessed cantly correlated with self-reports of general distress and in-
by one of the experienced and one of the inexperienced raters. terpersonal problems. This assumption was confirmed in three
The intraclass correlation coefficient (ICC) for a single rater clinical samples (Benecke et al., 2009; Mestel et al., 2004;
assessing the global score was .67. Spitzer et al., 2002a, 2004). General distress was measured by
Taken together, these studies led to two conclusions: First, the Symptom Checklist (SCL–90–R; Derogatis, 1977) or the
the OPD–LSIA shows good interrater reliability when ratings Brief Symptom Inventory (BSI; Derogatis, 1993), and interper-
are conducted by trained and experienced clinicians. In this sonal problems were assessed using the Inventory of Interper-
case, even reliabilities of single OPD dimensions were close to sonal Problems–Circumplex (IIP–C; Alden, Wiggins, & Pincus,
the threshold of .75 proposed by Bender et al. (2011, p. 340). 1990). Correlations between the OPD–LSIA global score and
Second, clinical experience seems to facilitate a reliable rating of self-reported general distress were significant in two out of three
the OPD–LSIA, as reliability estimates were consistently lower samples and averaged to rs = .37. Correlations with the self-
when raters without clinical experience were involved. However, reported severity of interpersonal problems were significant in
it should be noted that even in this case, the reliability of the all samples and ranged from .24 to .45. Thus, there is good evi-
global score was in the range of what is intended for dimensional dence that the level of structural integration is at least moderately
ratings in DSM–5 (Kraemer, Kupfer, Clarke, Narrow, & Regier, associated with self-reported general distress and interpersonal
2012). problems.
Third, studies have shown that ratings of the OPD–LSIA
Validity. Data from 17 independent samples including are associated with various clinically relevant variables. For
more than 2,000 persons support the validity of the OPD–LSIA example, patients with a lower level of structural integration
(Benecke et al., 2009; Böker et al., 2008; Doering et al., 2012; have a more negative body concept (G. Schneider et al., 2008),
Grande, Rudolf, & Oberbracht, 1998; Grande, Schauenburg, & show more insecure attachment styles (Schauenburg, 2000),
Rudolf, 2002; Grande et al., 2006; Grütering & Schauenburg, treat themselves and others in a more hostile way (Mestel et al.,
2000; Hill, Ujeyl, Habermann, Berner, & Briken, 2008; Mestel, 2004), are prone to self-injurious behavior (Böker et al., 2008;
Klingelhöfer, Dahlbender, & Schüßler, 2004; Müller, Kaufhold, Spitzer et al., 2002a), are more likely to experience psychotic
526 ZIMMERMANN ET AL.

symptoms (Uzdawinis et al., 2010), have a longer duration of OPD–LSIA and PD was r = .42 with a 95% confidence interval
mental illness (Rudolf et al., 1996), and tend to be indicated for of .32 to .51. Thus, in patients with a PD, the level of structural
psychiatric rather than psychotherapeutic treatment (G. Schnei- integration was substantially lower than in patients without a
der et al., 2002). Moreover, there is some evidence that a bet- PD, representing a moderate to large effect size (Cohen, 1988).
ter level of structural integration is advantageous in terms of Some further results seem noteworthy: Doering et al. (2012)
symptom change or treatment success, as judged by patients or found that patients with cluster C PDs (avoidant, dependent,
therapists (Müller et al., 2006; Rudolf et al., 1996; Spitzer et al., and obsessive–compulsive) had a significantly better level of
2004; Strauß et al., 1997; but also see Thomasius et al., 2001). structural integration than those with cluster B PDs (histrionic,
narcissistic, borderline, and antisocial), replicating results from
Associations with personality disorder diagnoses. Given an earlier study by Grande et al. (1998). This is in line with
that the OPD–LSIA captures core features of personality pathol- psychodynamic assumptions about severity differences between
ogy, one would expect substantial associations with observer rat- specific PDs (Kernberg & Caligor, 2005), and roughly corre-
ings of PDs. We explored this issue by means of a meta-analysis sponds to recent empirical findings published by members of the
(Borenstein, Hedges, Higgins, & Rothstein, 2009). Data were DSM–5 Work Group (Morey et al., 2011). Moreover, Benecke
based on 775 participants from eight studies that applied the et al. (2009) investigated the relation between the OPD–LSIA
OPD–LSIA in conjunction with observer ratings of PDs (Be- and comorbidity according to DSM–IV. Comorbidity was as-
necke et al., 2009; Böker et al., 2008; Doering et al., 2012; sessed using Structured Clinical Interviews for DSM–IV Axis I
Grande et al., 2006; Grande et al., 1998; Grütering & Schauen- and II Disorders (SCID–I; First, Spitzer, Gibbon, & Williams,
burg, 2000; Nitzgen & Brünger, 2000; Spitzer et al., 2002a). 2002; SCID–II: First, Gibbon, Spitzer, Williams, & Benjamin,
Table 2 presents detailed information on sample characteristics, 1997). All OPD–LSIA dimensions were highly significantly
features of the rating process, and effect sizes (r) of the asso- correlated with comorbidity according to DSM–IV (i.e., with
ciation between the OPD–LSIA global score and the presence number of Axis I diagnoses, number of PD diagnoses, and to-
of a PD. The majority of participants were recruited in psy- tal number of diagnoses). Interestingly, the OPD–LSIA global
chotherapy inpatient clinics, covering a broad range of mental score was much more highly correlated with the number of
disorders. The mean prevalence rate of PDs was 48.9%, which PDs, rs = .63, than with the number of DSM Axis I disorders,
is quite typical for clinical samples (Zimmerman, Rothschild, & rs = .34, z = 3.24, p < .01. This finding is in line with the as-
Chelminski, 2005). All studies employed trained and clinically sumption that the OPD–LSIA does not merely capture general
experienced OPD–LSIA raters. In six samples, OPD–LSIA rat- psychopathology, but rather specific impairments in personal-
ings were based on videotaped OPD interviews; in five samples, ity functioning. Taken together, the results show a substantial
OPD–LSIA ratings and PD ratings were conducted by indepen- and specific relation between the level of structural integration
dent raters; and in three samples, PD diagnoses were assessed and observer reports of PDs. Thus, the OPD–LSIA seems to be
using structured clinical interviews. Adopting a random effects well-suited to serve as a measure for the severity of personality
model, the mean effect size for the association between the pathology.

TABLE 2.—Study characteristics and effect sizes of personality disorder diagnoses in eight OPD-LSIA studies.

Sample Characteristics Rating Characteristics Effect sizes of PD

M %
Type N Age Female % PD Data Rater κ/ICC Instrument rs

Benecke et al. (2009) Inpatients, mixed 105 34.5 85.7 38.1 vt. OPD-interview 2 .65–.83 SCID–II .57∗∗b
diagnoses, and healthy
controls
Böker et al. (2008) Psychiatric inpatients, 40 42.9 100.0 37.5 vt. OPD-interview 1 — IDCL–P .33∗
depression
Doering et al. (2012) Inpatients and outpatients, 125 40.8 68.8 62.4 vt. OPD-interview 2 .67 SCID–II .48∗∗
mixed diagnoses
Grande et al. (1998) Inpatients, mixed 100 29.3 75.0 54.0 vt. OPD-interview 2 N/A Clinical judgment .23∗a
diagnoses
Grande et al. (2006) Outpatients, mixed 59 37.4 66.1 52.5 vt. OPD-interview 2 N/A Clinical judgmentDR .62∗∗b
diagnoses
Grütering & Inpatients, mixed 49 35.8 59.2 28.6 vt. OPD-interview 2 .43 Clinical judgment .21b
Schauenburg (2000) diagnoses
Nitzgen & Brünger Inpatients, alcohol 141 42.1 0.0 71.6 OPD-interview 1 — Clinical judgmentDR .38∗∗a
(2000) dependence
Spitzer et al. (2002a) Psychiatric inpatients, 156 39.7 73.7 29.5 Consensus 1 — Clinical judgmentR .41∗∗b
mixed diagnoses conference after
treatment

Note. PD = Personality Disorder; κ = weighted kappa; ICC = intraclass correlation coefficient; SCID –II = Structured Clinical Interview for DSM–IV Axis II Disorders (First
et al., 1997); IDCL–P = International Diagnostic Checklists for Personality Disorders according to ICD–10 and DSM–IV (Bronisch, Hiller, Zaudig, & Mombour, 1995); rs = Spearman
correlation with Operationalized Psychodynamic Diagnostic system Levels of Structural Integration Axis (OPD–LSIA) total score; vt. = videotaped; N/A = not available.
a
Effect size was computed afterward based on published data. bSpearman correlation was computed afterward based on the original data provided by the authors.
Study limitations: ROPD–LSIA and personality disorder measure were assessed by the same rater. DOPD–LSIA and personality disorder measure were based on the same data source.
∗
p < .05. ∗∗ p < .001.
LEVEL OF STRUCTURAL INTEGRATION 527

MAPPING LEVELS OF PERSONALITY FUNCTIONING 4

ONTO LEVELS OF STRUCTURAL INTEGRATION
We have demonstrated so far that the OPD–LSIA fulfills the

Expert-rated OPD-LSIA level

criteria of an instrument that could inform the DSM–5 revision
process (Bender et al., 2011): The OPD–LSIA contains salient
mental functioning dimensions, has an explicit self–other focus, 3
and has been successfully employed in studies with both general
clinical and personality-disordered samples. Furthermore, it is
useful for a broad range of clinicians as it relates to the psy-
chodynamic concept of personality structure, it is applicable to
rating clinical interview material, and it has adequate psychome- 2
tric properties. In the following section, we clarify how exactly
the OPD–LSIA could contribute to the current LPFS version.
We propose that the OPD–LSIA can serve as a standard of com-
parison for assessing the comprehensiveness of both the sever-
ity dimension and the content domains of the LPFS. Thereby, 1
possible limitations of the current LPFS proposal might come 0 1 2 3 4
into view. To provide a first empirical basis for our proposi- Theoretical LPFS level
tion, we conducted (a) an empirical study mapping consensual
impressions of the LPFS item set onto the OPD–LSIA frame- FIGURE 1.—Mapping Levels of Personality Functioning Scale (LPFS) levels
work, and (b) a secondary data analysis exploring the empirical onto OPD Levels of Structural Integration Axis (OPD–LSIA) levels.
relevance of the OPD–LSIA subdimensions that are not suf-
ficiently covered by the LPFS item set. Taken together, our
results provide information on empirically relevant gaps in the
LPFS proposal. By this, we hope to support the DSM–5 Work 0, 1, and 2 items were relatively clear-cut: In our assessment,
Group’s task of constructing an optimal measure of personality these levels corresponded to mean OPD–LSIA scores of 1.02
functioning. (SD = .03), 1.88 (0.20), and 2.46 (0.31), respectively. By con-
trast, the boundaries between the LPFS Level 2, 3, and 4 items
seemed to be much fuzzier: On average, LPFS Levels 3 and
Exploring the Comprehensiveness of the LPFS Item Set 4 corresponded to mean OPD levels of 2.87 (0.28) and 3.12
To explore the comprehensiveness of the LPFS item set from (0.27). A post-hoc test with Bonferroni correction showed that
the perspective of the OPD–LSIA, we conducted an OPD expert the difference between LPFS Levels 3 and 4 was not signif-
consensus study. The six authors of this article independently icant, p = .13. Thus, a considerable proportion of the LPFS
rated the 60 descriptors of the LPFS in terms of the OPD–LSIA. items pertaining to Levels 2, 3, and 4 were indistinguishable
More specifically, we assessed (a) the OPD level of structural from an OPD perspective, roughly representing a “low” level
integration that corresponds to a given item description (using of structural integration. For example, “Excessive dependence
a 40-point scale from 1.0 [good integration] to 4.0 [disinte- on others for identity definition, with compromised boundary
gration]) and (b) the extent to which a given item description delineation,” “Emotions may be rapidly shifting or a chronic,
captures the content of the OPD subdimensions (using 24 four- unwavering feeling of despair,” and “Weak or distorted self-
point scales from 0 [not at all] to 3 [precisely]). The LPFS items image easily threatened by interactions with others; significant
were presented in a random order, without information about the distortions and confusion around self-appraisal” received aver-
proposed level and dimension. Interrater reliability was good. age OPD ratings of 2.97, 3.05, and 2.82, respectively. These are
In particular, there was high agreement about which items as- at odds with the theoretical assignments of the DSM–5 Work
sess high versus low levels of structural integration. The ICC Group, which define these items as descriptors of moderate (2),
for the composite ratings was .97. Moreover, for the majority of severe (3), and extreme (4) identity disturbances, respectively.
items, the six raters substantially agreed about which OPD struc- Third, the LPFS items do not sufficiently cover the “disinte-
tural subscales are captured by the LPFS item descriptions. The grated” level of structural integration of the OPD. Only 1 out
replicability coefficients (Cronbach’s alpha) for the composite of 12 LPFS items describing extreme personality dysfunction
profiles had a median value of .86 and ranged from .19 to .98. received a mean OPD rating greater than 3.5 (i.e., “Internal stan-
We used only the composite ratings or profiles for subsequent dards for behavior are virtually lacking. Genuine fulfillment is
analyses. virtually inconceivable”). Thus, the proposed LPFS might not
Figure 1 shows the relation between the theoretically pro- be able to discriminate between low integrated and disintegrated
posed LPFS level (horizontal axis) and the empirically rated personality structures, and therefore, would not be useful for di-
OPD level of structural integration (vertical axis) across the agnosing extreme psychopathology (e.g., in the field of forensic
60 items. Several results seem noteworthy: First, there was psychiatry; Hill et al., 2008).
a substantial conceptual overlap between the two severity di- Table 3 summarizes the composite ratings on the extent to
mensions. In fact, the correlation between the two dimensions which the LPFS domains correspond to OPD subdimensions.
across 60 items was r = .93, p < .001. This confirms that the When looking across the rows, one sees the amount of overlap of
OPD–LSIA is highly similar to the proposed LPFS, with both an OPD subdimension with the LPFS domains of identity, self-
measures sharing a common severity continuum. Second, from direction, empathy, and intimacy. For this purpose, we computed
our OPD perspective, the boundaries between the LPFS Level the means (and standard deviations) on an OPD subdimension
528 ZIMMERMANN ET AL.

TABLE 3.—Mapping LPFS dimensions onto OPD–LSIA subdimensions.

LPFS Dimensions
Identity Self-Direction Empathy Intimacy Full Scale
OPD–LSIA Dimensions and Subdimensions M SD M SD M SD M SD M SD

Self-perception
Self-reflection 0.46 0.50 1.14 1.25 0.11 0.20 0.00 0.00 0.43 0.80
Affect differentiation 0.40 0.65 0.31 0.41 0.00 0.00 0.00 0.00 0.18 0.42
Identity 1.13 1.10 0.93 0.32 0.02 0.09 0.08 0.12 0.54 0.75
Object perception
Self–object differentiation 0.70 0.81 0.13 0.26 0.49 0.32 0.30 0.29 0.41 0.52
Whole object perception 0.06 0.12 0.02 0.09 0.87 0.55 0.47 0.42 0.35 0.49
Realistic object perception 0.09 0.21 0.02 0.09 1.08 0.51 0.47 0.32 0.41 0.53
Self-regulation
Affect tolerance 0.20 0.32 0.40 0.36 0.00 0.00 0.08 0.12 0.17 0.28
Impulse control 0.62 0.80 0.10 0.16 0.03 0.09 0.03 0.09 0.20 0.47
Regulation of self-esteem 1.06 1.18 0.26 0.33 0.03 0.09 0.17 0.27 0.38 0.73
Regulation of relationships
Protecting relationships 0.09 0.14 0.01 0.04 0.32 0.31 0.72 0.32 0.29 0.36
Balancing interests 0.09 0.14 0.06 0.12 0.71 0.66 1.22 0.90 0.52 0.73
Anticipation 0.03 0.09 0.10 0.16 0.86 0.85 0.23 0.30 0.31 0.55
Internal communication
Experiencing affect 0.58 0.78 0.32 0.35 0.00 0.00 0.01 0.04 0.23 0.48
Use of fantasies 0.03 0.07 0.28 0.26 0.01 0.04 0.06 0.14 0.09 0.19
Bodily self 0.04 0.12 0.03 0.09 0.00 0.00 0.00 0.00 0.02 0.08
External communication
Making contact 0.09 0.15 0.09 0.17 0.21 0.33 0.40 0.43 0.20 0.31
Communicating affect 0.07 0.15 0.02 0.09 0.10 0.23 0.16 0.30 0.09 0.21
Empathy 0.03 0.09 0.04 0.13 1.54 0.64 0.47 0.39 0.52 0.72
Attachment to internal objects
Internalization 0.08 0.12 0.13 0.14 0.00 0.00 0.18 0.32 0.10 0.19
Use of introjects 0.09 0.15 0.24 0.27 0.00 0.00 0.03 0.07 0.09 0.18
Variability of attachment patterns 0.03 0.09 0.00 0.00 0.09 0.12 0.29 0.28 0.10 0.19
Attachment to external objects
Capacity for attachment 0.08 0.22 0.07 0.12 0.19 0.21 1.28 0.81 0.40 0.67
Accepting help 0.00 0.00 0.03 0.09 0.02 0.06 0.14 0.20 0.05 0.12
Detaching from relationships 0.01 0.04 0.00 0.00 0.03 0.09 0.09 0.18 0.03 0.11

Note. Means and standard deviations for identity, self-direction, empathy, and intimacy are based on composite ratings of 15 DSM–5 items, respectively. LPFS = Levels of Personality
Functioning Scale; OPD–LSIA = Operationalized Psychodynamic Diagnostic system Levels of Structural Integration Axis. All ratings were conducted on 4-point scales with 0 = not at
all, 1 = vague, 2 = roughly, and 3 = precisely.

for the four sets of 15 LPFS items, respectively. For example, we inner experience with the help of fantasies and prepare creative
found that OPD self-reflection is mostly captured by LPFS self- solutions (use of fantasies), to realistically describe and feel
direction items (M = 1.14), but has almost nothing in common alive in one’s own body (bodily self), to communicate emotional
with items representing LPFS empathy (M = 0.11) or LPFS states and be receptive to others’ emotions (communicating
intimacy (M = 0.00). Down each column are the OPD profiles affect), to develop and maintain emotional, stable, internal im-
for each LPFS domain. We used an arbitrary value of 0.50 for ages of significant others (internalization), to care for and calm
defining a relevant peak in the profile. Accordingly, the LPFS oneself based on internalized positive relationship experiences
domain of identity is best represented by the OPD subdimen- (use of introjects), to develop diverse and rich internal images of
sions of identity (M = 1.13), regulation of self-esteem (M = important others and engage in triadic relationships (variability
1.06), self–object differentiation (M = 0.70), impulse control of attachment patterns), to resort to other people as good objects
(M = 0.62), and experiencing affect (M = 0.58); LPFS self- (accepting help), and to tolerate separations and withdraw affec-
direction is best represented by OPD self-reflection (M = 1.14) tive investments from lost objects (detaching from relationships;
and identity (M = 0.93); LPFS empathy is best represented by all M ≤ 0.10). This suggests that the capacities for communi-
OPD empathy (M = 1.54), realistic object perception (M = cation and attachment are conceptualized in a broader way in
1.08), whole object perception (M = 0.87), anticipation (M = the OPD–LSIA than in the LPFS, as they additionally capture
0.86), and balancing interests (M = 0.71); and LPFS intimacy aspects related to the self, the body, and the inner world of an
is best represented by OPD attachment capacity (M = 1.28), individual.1
balancing interests (M = 1.22), and protecting relationships
(M = 0.72).
The last column of Table 3 presents the OPD profile for the 1Conversely, our data can also be used to assess which LPFS domains and
full LPFS item set. This profile is of particular interest because items are underrepresented in the OPD–LSIA framework. Bonferroni-corrected
it indicates which OPD subdimensions are underrepresented in post-hoc tests revealed that LPFS items representing intimacy and empathy
the current DSM–5 proposal. Features that were not or rarely could be better matched to OPD subdimensions than items representing self-
covered by LPFS items include the ability to broaden one’s own direction, ps < .01. For example, OPD experts have failed to consensually find
LEVEL OF STRUCTURAL INTEGRATION 529

Exploring the Empirical Relevance of the Missing search that was previously not recognized by the DSM–5 Work
OPD–LSIA Subdimensions Group. Additionally, we suggest that the OPD–LSIA could serve
One might argue that these missing OPD subdimensions do as a criterion measure in LPFS validation studies.
not substantially add to the global continuum of personality The further process of calibrating and refining the LPFS will
functioning as defined by the LPFS. In fact, this is an empirical be mainly guided by results from the official DSM–5 Field Tri-
question, and should be answered by future research conjointly als, investigating reliability, feasibility, and acceptability of the
applying the LPFS and OPD–LSIA in one sample. Neverthe- current LPFS proposal (Skodol, 2012). However, two findings
less, a first step in empirically corroborating the relevance of from our OPD expert consensus study might also be relevant
the missing OPD subdimensions is to show their incremental for the DSM–5 Work Group’s task of finalizing the LPFS: First,
validity in predicting personality pathology above and beyond we found that a considerable proportion of LPFS items per-
the OPD–LSIA global score. Therefore, we conducted a sec- taining to Levels 2, 3, and 4 were hardly distinguishable from
ondary data analysis using a sample of 103 individuals cover- an OPD perspective. As a consequence, the currently proposed
ing the full spectrum of personality pathology (Benecke et al., LPFS might not sufficiently discriminate between individuals
2009; see earlier). We recruited an additional OPD rater to judge with moderate, severe, and extreme personality dysfunction. Of
each person on all 24 subdimensions based on archived OPD course, we cannot rule out that our findings were biased by
videotapes. The criterion measure of general PD severity re- a priori opinions regarding the LPFS or limited by using the
lied on data from the SCID–II. More specifically, we followed OPD–LSIA as the frame of reference. We therefore suggest
Hopwood et al. (2011) in summing the dichotomously scored replicating our study with proponents of other models of PD
criteria of all 10 DSM–IV PDs. In our sample, the SCID–II sum- severity, or with lay persons without any explicit model. This
mary score ranged from 0 to 35, with a mean value of 8.01 (SD would help to validate, or even improve, the current LPFS item
= 8.00). To assess the incremental validity of the eight missing assignments along the severity continuum. Second, we found
subdimensions, we conducted a series of hierarchical regression that the current LPFS item set does not capture the full range
analyses predicting SCID–II severity by the OPD–LSIA global of communication and attachment capacities as defined by the
score in the first step, and respective OPD subdimension ratings OPD–LSIA. Results from a secondary data analysis suggested
in the second step. As expected, the OPD–LSIA global score that the empirically most relevant gaps were the capacities to
was a highly significant predictor in the first step, r = .63, p < realistically describe and feel alive in one’s own body (bodily
.001. Furthermore, bodily self, sr = .18, p < .05; communicat- self), to communicate emotional states and be receptive to oth-
ing affect, sr = –.18, p < .05; and use of introjects, sr = .16, ers’ emotions (communicating affect), and to care for and calm
p < .05, predicted additional variance in the second step. This is oneself based on internalized positive relationship experiences
the first evidence that at least three OPD subdimensions that are (use of introjects). As the DSM–5 Work Group will rather sim-
currently missing in the LPFS proposal are indeed empirically plify than elaborate on the LPFS (Skodol, 2012, p. 334), it is
relevant in predicting general PD severity. unrealistic to hope that these (or related) aspects will be included
in the final version. Nevertheless, we propose that future studies
IMPLICATIONS FOR DSM–5 should assess whether disruptions or delays in the normative
Introducing the LPFS into DSM–5 represents a major shift development of these capacities are incrementally predictive of
in the classification of PD (Skodol, Clark, et al., 2011). Thus, the general level of personality functioning.
it is crucial that the DSM–5 Work Group is fully aware of ex- Finally, we want to highlight some lessons learned from
isting approaches to the dimensional assessment of personality working with the OPD–LSIA that might be important for the
functioning, being able to build on their empirical evidence LPFS. For example, the results on the interrater reliability of
and to learn from their strengths and weaknesses. In line with the OPD–LSIA underscore that a reliable rating of personal-
this reasoning, we introduced the OPD–LSIA, a clinician-rated ity structure is an ambitious task that requires several hours of
measure of personality functioning that is rooted in psychody- training and is facilitated by clinical experience. Thus, is seems
namic theory and widely used in German-speaking countries worthwhile to develop a standard training for the LPFS (draw-
(OPD Task Force, 2008; Schauenburg & Grande, 2011). Our ing on videotaped interviews or case vignettes), which might
OPD expert consensus study unequivocally confirmed that the help to improve reliability in research contexts. Another issue
OPD–LSIA is highly similar to the proposed LPFS and that is the method of data collection. The OPD–LSIA is normally
both measures share a common severity continuum. Moreover, rated based on an OPD interview, which combines an open,
our review showed that trained and experienced clinicians can unstructured interview procedure with structured questions on
reliably apply the OPD–LSIA to clinical interview material, and biographic and clinical details (OPD Task Force, 2008). This
that its validity is well supported by data from more than 2,000 method deviates from semistructured interviews recommended
participants. Most important, the global score of the OPD–LSIA for the assessment of PD (Widiger & Samuel, 2005) because
exhibited substantial and specific associations with observer rat- the interviewer is encouraged to draw on the interviewee’s em-
ings of PDs, corroborating its use as an index for the severity phases, omissions, nonverbal behaviors, and reenactments, as
of personality pathology. These findings broaden and strengthen well as on his or her own countertransference feelings (Westen,
the empirical base of the LPFS by bringing to mind a body of re- 1997). From our experience with the OPD–LSIA, these ad-
ditional data sources are of great importance because impair-
ments in basic capacities are especially apparent in how the
an OPD subdimension that captures the ability to “utilize appropriate standards interviewee copes with the demands of the interview situation.
of behavior, attaining fulfillment in multiple realms.” Although not central to Thus, we look forward to empirical investigations clarifying
this article, this finding might be important for future revisions of the OPD which method of data collection is optimally suited for an ap-
system. plication of the LPFS. A final issue that should be noted is
530 ZIMMERMANN ET AL.

sensitivity to change. Grande, Rudolf, and Oberbracht (2000) Böker, H., Himmighoffen, H., Straub, M., Schopper, C., Endrass, J., Küchen-
found that the OPD–LSIA global scores did not change dur- hoff, B., . . . Hell, D. (2008). Deliberate self-harm in female patients with
ing 12 weeks of intensive inpatient psychotherapy. As a conse- affective disorders: Investigation of personality structure and affect regulation
quence, they developed the Heidelberg Structural Change Scale by means of operationalized psychodynamic diagnostics. Journal of Nervous
and Mental Disease, 2196, 743–751. doi:10.1097/NMD.0b013e3181879daf
(HSCS), which requires selecting specific problem areas for
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009).
each patient prior to treatment (e.g., one of the eight primary Introduction to meta-analysis. Chichester, UK: Wiley.
OPD–LSIA dimensions), and subsequently assessing changes Bornstein, R. F. (2003). Behaviorally referenced experimentation and symp-
in the way the patient dealt with the selected problem areas. tom validation: A paradigm for 21st-century personality disorder research.
In applying the HSCS, Grande et al. (2009) showed that struc- Journal of Personality Disorders, 17, 1–18. doi:10.1521/pedi.17.1.1.24056
tural change during psychoanalytic long-term psychotherapy Bornstein, R. F. (2011). Reconceptualizing personality pathology in DSM–5:
was predictive of the outcome at a 3-year follow-up. We sug- Limitations in evidence for eliminating dependent personality disorder and
gest that developing individualized assessment strategies like other DSM–IV syndromes. Journal of Personality Disorders, 25, 235–247.
the HSCS might help to prepare the LPFS for assessing change doi:10.1521/pedi.2011.25.2.235
over time. Bronisch, T., Hiller, W., Zaudig, M., & Mombour, W. (1995). IDCL-
Besides these concerns, we highly appreciate the introduc- P—Internationale Diagnosen Checklisten für Persönlichkeitsstörungen nach
ICD–10 und DSM–IV (Manual) [IDCL–P: International Diagnostic Check-
tion of the LPFS in DSM–5. From our perspective, assessing
lists for Personality Disorders according to ICD–10 and DSM–IV (Manual)].
the severity of PD along a continuum of self and interpersonal Bern, Switzerland: Huber.
functioning is a major step forward in the classification of PD, as Cierpka, M., Grande, T., Rudolf, G., von der Tann, M., & Stasch, M. (2007). The
it brings the DSM–5 toward what psychodynamically oriented Operationalized Psychodynamic Diagnostics system: Clinical relevance, reli-
clinicians have done successfully for many years. In this sense, ability and validity. Psychopathology, 40, 209–220. doi:10.1159/000101363
the LPFS represents the long-awaited reconciliation of psychi- Cierpka, M., Grande, T., Stasch, M., Oberbracht, C., Schneider, W., Schüßler,
atric and psychodynamic approaches to diagnosing personality G., . . . Schneider, G. (2001). Zur Validität der Operationalisierten Psycho-
pathology (Westen, 1997; Westen et al., 2006). Of course, much dynamischen Diagnostik (OPD)) [About the validity of the Operationalized
work is still to be done. For example, the official DSM–5 Field Psychodynamic Diagnostics (OPD)]. Psychotherapeut, 46, 122–133.
Clark, L. (2007). Assessment and diagnosis of personality disorder: Perennial
Trials should be complemented by further studies investigating
issues and an emerging reconceptualization. Annual Review of Psychology,
the construct validity of the LPFS. Until now, research on the 58, 227–257. doi:10.1146/annurev.psych.57.102904.190200
validity of related scales (including the OPD–LSIA) has been Clarkin, J. F., Caligor, E., Stern, B. L., & Kernberg, O. F. (2004). Structured
almost completely based on self- and clinician reports. It will be Interview of Personality Organization (STIPO). Unpublished manuscript,
of great importance to extend the nomological net of the LPFS to Personality Disorders Institute, Weill Medical College of Cornell University,
actual behavior (e.g., performance on standard interaction tasks; New York, NY.
Leising, Krause, Köhler, Hinsen, & Clifton, 2011), and to use Cohen, J. (1968). Weighted kappa: Nominal scale agreement provision for
experimental designs for the validation of differences between scaled disagreement or partial credit. Psychological Bulletin, 70, 213–220.
levels (Bornstein, 2003). We look forward to years of stimulat- doi:10.1037/h0026256
ing research that will bridge the gap between psychiatric and Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd
ed.). Hillsdale, NJ: Erlbaum.
psychodynamic approaches to personality pathology.
Crawford, M. J., Koldobsky, N., Mulder, R., & Tyrer, P. (2011). Classifying
personality disorder according to severity. Journal of Personality Disorders,
REFERENCES 25, 321–330. doi:10.1521/pedi.2011.25.3.321
Alden, L. E., Wiggins, J. S., & Pincus, A. L. (1990). Construction of circumplex Dahlbender, R. W., Rudolf, G., & OPD Task Force. (2006). Psychic structure and
scales for the Inventory of Interpersonal Problems. Journal of Personality mental functioning: Current research on the reliable measurement and clinical
Assessment, 55, 521–536. doi: 10.1080/00223891.1990.9674088 validity of Operationalized Psychodynamic Diagnostics (OPD) System. In
American Psychiatric Association. (2000). Diagnostic and statistical manual of Task Force PDM (Ed.), Psychodynamic diagnostic manual (pp. 615–662).
mental disorders (4th ed., text revision). Washington, DC: American Psychi- Silver Spring, MD: Alliance of Psychoanalytic Organizations.
atric Association. Derogatis, L. R. (1977). SCL–90–R: Administration, scoring, and procedures
Azim, H. F. A., Piper, W. E., Segal, P. M., Nixon, G. W. H., & Duncan, S. (1991). manual-I for the R(evised) version. Baltimore, MD: Johns Hopkins Univer-
The quality of object relations scale. Bulletin of the Menninger Clinic, 55, sity, School of Medicine.
323–343. Derogatis, L. R. (1993). Brief Symptom Inventory: Administration, scoring and
Bender, D. S., Morey, L. C., & Skodol, A. E. (2011). Toward a model for procedures manual (4th ed.). Minneapolis, MN: NCS, Pearson.
assessing level of personality functioning in DSM–5, Part I: A review Doering, S., Burgmer, M., Heuft, G., Menke, B., Feldmann, M., Lübking, M.,
of theory and methods. Journal of Personality Assessment, 93, 332–346. . . . Schneider, G. (2012). Validity of the Levels of Structural Integration
doi:10.1080/00223891.2011.583808 Axis of the Operationalized Psychodynamic Diagnosis (OPD). Manuscript in
Benecke, C., Koschier, A., Peham, D., Bock, A., Dahlbender, R. W., Biebl, W., & preparation.
Doering, S. (2009). Erste Ergebnisse zu Reliabilität und Validität der OPD–2 Ehrenthal, J. C., Dinger, U., Horsch, L., Komo-Lang, M., Klinkerfuß, M.,
Strukturachse [First results on the reliability and validity of the OPD–2 axis Grande, T., & Schauenburg, H. (2012). Der OPD-Strukturfragebogen (OPD-
structure]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 55, SF): Erste Ergebnisse zu Reliabilität und Validität [The OPD structure ques-
84–96. tionnaire (OPD-SQ). First results on reliability and validity]. Psychosomatik,
Bernardi, R. (2010). DSM–5, OPD–2 y PDM: Convergencias y divergencias Psychotherapie, Medizinische Psychologie, 62, 25–32. doi:10.1055/s-0031-
entre los nuevos sistemas diagnósticos psiquiátrico y psicoanalı́ticos [DSM–5, 1295481
OPD–2, and PDM: Commonalities and differences of new psychiatric and First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L.
psychoanalytic diagnostic systems]. Revista de Psiquiatrı́a del Uruguay, 74, S. (1997). Structured Clinical Interview for DSM–IV Axis II personality
179–205. disorders (SCID–II). Washington, DC: American Psychiatric Press.
Blatt, S. J., Chevron, E. S., Quinlan, D. M., Schaffer, C. E., & Wein, S. (1992). First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2002). Structured
The assessment of qualitative and structural dimensions of object represen- Clinical Interview for DSM–IV–TR Axis I disorders (SCID–I). New York,
tations. Unpublished manuscript, Yale University, New Haven, CT. NY: Biometrics Research, New York State Psychiatric Institute.
LEVEL OF STRUCTURAL INTEGRATION 531

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning Leising, D., Krause, S., Köhler, D., Hinsen, K., & Clifton, A. (2011). Assess-
manual, version 5.0, for application to adult attachment interviews. London, ing interpersonal functioning: Views from within and without. Journal of
UK: University College London. Research in Personality, 45, 631–641. doi:10.1016/j.jrp.2011.08.011
Gamache, D., Laverdiere, O., Diguer, L., Hebert, E., Larochelle, S., & Leising, D., & Zimmermann, J. (2011). An integrative conceptual framework
Descoteaux, J. (2009). The Personality Organization Diagnostic Form: De- for assessing personality and personality pathology. Review of General Psy-
velopment of a revised version. The Journal of Nervous and Mental Disease, chology, 15, 317–330. doi:10.1037/a0025070
197, 368–377. doi:10.1097/NMD.0b013e3181a20897 Lenzenweger, M. F., Clarkin, J. F., Kernberg, O. F., & Foelsch, P. A. (2001).
Grande, T., Dilg, R., Jakobsen, T., Keller, W., Krawietz, B., Langer, M., . . . The Inventory of Personality Organization: Psychometric properties, factorial
Rudolf, G. (2006). Differential effects of two forms of psychoanalytic ther- composition, and criterion relations with affect, aggressive dyscontrol, psy-
apy: Results of the Heidelberg–Berlin study. Psychotherapy Research, 16, chosis proneness, and self-domains in a nonclinical sample. Psychological
470–485. doi:10.1080/10503300600608082 Assessment, 13, 577–591. doi:10.1037/1040-3590.13.4.577
Grande, T., Dilg, R., Jakobsen, T., Keller, W., Krawietz, B., Langer, Livesley, W. J. (1998). Suggestions for a framework for an empirically based
M., . . . Rudolf, G. (2009). Structural change as a predictor of long-term classification of personality disorder. The Canadian Journal of Psychiatry /
follow-up outcome. Psychotherapy Research, 19, 344–357. doi:10.1080/ La Revue canadienne de psychiatrie, 43, 137–147.
10503300902914147 Livesley, W. J. (2012). Tradition versus empiricism in the current DSM–5 pro-
Grande, T., Rudolf, G., & Oberbracht, C. (1998). Die Strukturachse der Opera- posal for revising the classification of personality disorders. Criminal Be-
tionalisierten Psychodynamischen Diagnostik (OPD): Forschungsergebnisse haviour and Mental Health, 22, 81–90. doi:10.1002/cbm.1826
zum Konzept und zur klinischen Anwendung [The structure axis of Opera- Mestel, R., Klingelhöfer, J., Dahlbender, R. W., & Schüßler, G. (2004). Va-
tionalized Psychodynamic Diagnosis (OPD): Research findings on its concept lidität der OPD-Achsen Konflikt und Struktur in der stationären psychoso-
and clinical application]. Persönlichkeitsstörungen, 2, 173–182. matischen Rehabilitation [Validity of the OPD conflict and structure axes
Grande, T., Rudolf, G., & Oberbracht, C. (2000). Veränderungsmessung auf in inpatient psychotherapy]. In R. W. Dahlbender, P. Buchheim, & G.
OPD-Basis: Schwierigkeiten und ein neues Konzept [OPD-based assessment Schüßler (Eds.), Lernen an der Praxis: OPD und Qualitätssicherung in
of change: Difficulties and a new concept]. In W. Schneider & H. J. Freyberger der Psychodynamischen Psychotherapie (pp. 229–244). Bern, Switzerland:
(Eds.), Was leistet die OPD? Empirische Befunde und klinische Erfahrungen Huber.
mit der Operationalisierten Psychodynamischen Diagnostik (pp. 148–161). Meyer, B., & Pilkonis, P. A. (2005). An attachment model of personality dis-
Bern, Switzerland: Huber. orders. In M. F. Lenzenweger & J. F. Clarkin (Eds.), Major theories of
Grande, T., Schauenburg, H., & Rudolf, G. (2002). Zum Begriff “Struktur” in personality disorder (2nd ed., pp. 231–281). New York, NY: Guilford.
verschiedenen Operationalisierungen. Ein empirischer Vergleich der “Scales Morey, L. C., Berghuis, H., Bender, D. S., Verheul, R., Krueger, R. F., &
of Psychological Capacities” und der “Operationalisierten Psychodynamis- Skodol, A. E. (2011). Toward a model for assessing level of personality
chen Diagnostik” [Different operationalizations of the concept of “structure”: functioning in DSM–5, Part II: Empirical articulation of a core dimension
An empirical comparison of the “Scales of Psychological Capacities” and the of personality pathology. Journal of Personality Assessment, 93, 347–353.
“Operationalized Psychodynamic Diagnosis”]. In G. Rudolf, T. Grande, & doi:10.1080/00223891.2011.577853
P. Henningsen (Eds.), Die Struktur der Persönlichkeit: Vom theoretischen Müller, C., Kaufhold, J., Overbeck, G., & Grabhorn, R. (2006). The impor-
Verständnis zur therapeutischen Anwendung des psychodynamischen Struk- tance of reflective functioning to the diagnosis of psychic structure. Psychol-
turkonzepts (pp. 177–196). Stuttgart, Germany: Schattauer. ogy and Psychotherapy: Theory, Research and Practice, 79, 485–494. doi:
Grütering, T. B., & Schauenburg, H. (2000). Die Erfassung psychodynamisch 10.1348/147608305×68048
relevanter Persönlichkeitsmerkmale—Vergleich zweier klinischer Instru- Nitzgen, D., & Brünger, M. (2000). Operationalisierte Psychodynamische Diag-
mente: Karolinska Psychodynamic Profile (KAPP) und OPD-Strukturachse nostik in der Rehabilitationsklinik Birkenbuck: Einsatz und Befunde [Opera-
[Assessment of psychodynamically relevant personality traits: A comparison tionalized psychodynamic diagnosis in the inpatient psychotherapeutic clinic
of the clinical instruments Karolinska Psychodynamic Profile (KAPP) and Birkenbuck: Application and results]. In W. Schneider & H. J. Freyberger
OPD structure axis]. In M. Bassler (Ed.), Leitlinien in der stationären Psy- (Eds.), Was leistet die OPD? Empirische Befunde und klinische Erfahrungen
chotherapie: Pro und Kontra (pp. 115–136). Gießen, Germany: Psychosozial. mit der Operationalisierten Psychodynamischen Diagnostik (pp. 238–252).
Hill, A., Ujeyl, M., Habermann, N., Berner, W., & Briken, P. (2008). Bern, Switzerland: Huber.
Schuldfähigkeit bei sexuellen Tötungsdelikten [Criminal responsibility in OPD Task Force. (Eds.). (2001). Operationalized Psychodynamic Diagnostics
sexual homicide perpetrators]. Fortschritte der Neurologie, Psychiatrie, 76, (OPD): Foundations and manual. Cambridge, MA: Hogrefe & Huber.
343–353. doi:10.1055/s-2008-1038194 OPD Task Force. (Eds.). (2008). Operationalized Psychodynamic Diagnosis
Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow C. A., Grillo, C. M., OPD–2: Manual of diagnosis and treatment planning. Cambridge, MA:
McGlashan, T. H., . . . Morey, L. C. (2011). Personality assessment in DSM–5: Hogrefe & Huber.
Empirical support for rating severity, style, and traits. Journal of Personality Parker, G., Both, L., Olley, A., Hadzi-Pavlovic, D., Irvine, P., & Jacobs, G.
Disorders, 25, 305–320. doi:10.1521/pedi.2011.25.3.305 (2002). Defining disordered personality functioning. Journal of Personality
Horowitz, L. M. (2004). Interpersonal foundations of psychopathology. Wash- Disorders, 16, 503–522. doi:10.1521/pedi.16.6.503.22139
ington, DC: American Psychological Association. doi:10.1037/10727-000 Pilkonis, P. A., Hallquist, M. N., Morse, J. Q., & Stepp, S. D. (2011). Striking the
Kernberg, O. F., & Caligor, E. (2005). A psychoanalytic theory of personality (im)proper balance between scientific advances and clinical utility: Commen-
disorders. In M. F. Lenzenweger & J. F. Clarkin (Eds.), Major theories of tary on the DSM–5 proposal for personality disorders. Personality Disorders:
personality disorder (2nd ed., pp. 114–156). New York, NY: Guilford. Theory, Research, and Treatment, 2, 68–82. doi:10.1037/a0022226
Kraemer, H. C., Kupfer, D. J., Clarke, D. E., Narrow, W. E., & Regier, D. A. Pincus, A. L. (2011). Some comments on nomology, diagnostic process, and
(2012). DSM–5: How reliable is reliable enough? American Journal of Psy- narcissistic personality disorder in the DSM–5 proposal for personality and
chiatry, 169, 13–15. doi:10.1176/appi.ajp.2011.11010050 personality disorders. Personality Disorders: Theory, Research, and Treat-
Krueger, R. F., Eaton, N. R., Derringer, J., Markon, K. E., Watson, D., & Skodol, ment, 2, 41–53. doi:10.1037/a0021191
A. E. (2011). Personality in DSM–5: Helping delineate personality disorder Rudolf, G. (2002). Struktur als psychodynamisches Konzept der Persönlichkeit
content and framing the metastructure. Journal of Personality Assessment, [Structure as a psychodynamic concept of personality]. In G. Rudolf, T.
93, 325–331. doi:10.1080/00223891.2011.577478 Grande, & P. Henningsen (Eds.), Die Struktur der Persönlichkeit. Vom the-
Leichsenring, F. (1999). Development and first results of the Borderline oretischen Verständnis zur therapeutischen Anwendung des psychodynamis-
Personality Inventory: A self-report instrument for assessing borderline chen Strukturkonzepts (pp. 2–48). Stuttgart, Germany: Schattauer.
personality organization. Journal of Personality Assessment, 73, 45–63. Rudolf, G., & Doering S. (2012). Die Strukturachse der Operationalisierten
doi:10.1207/S15327752JPA730104 Psychodynamischen Diagnostik (OPD) [The structure axis of Operationalized
532 ZIMMERMANN ET AL.

Psychodynamic Diagnosis (OPD)]. In S. Doering & S. Hörz (Eds.), Handbuch ality structure and symptom-related and interpersonal outcome of inpatient
der Strukturdiagnostik. Konzepte, Instrumente, Praxis (pp. 87–121). Stuttgart, psychotherapy]. Zeitschrift für Psychosomatische Medizin und Psychothera-
Germany: Schattauer. pie, 50, 70–85.
Rudolf, G., Grande, T., Oberbracht, C., & Jakobsen, T. (1996). Erste empirische Strauß, B., Hüttmann, B., & Schulz, N. (1997). Kategorienhäufigkeit und prog-
Untersuchungen zu einem neuen diagnostischen System: Die Operational- nostische Bedeutung einer operationalisierten psychodynamischen Diagnos-
isierte Psychodynamische Diagnostik (OPD) [First empirical investigations tik. Erste Erfahrungen mit der “OPD-1” im stationären Rahmenn [Category
on a new diagnostic system: The Operationalized Psychodynamic Diagnosis distribution and prognostic significance of operationalized psychodynamic
(OPD)]. Zeitschrift für Psychosomatische Medizin und Psychotherapie, 42, diagnosis. Initial experiences with “OPD-1” in inpatient psychotherapy]. Psy-
343–357. chotherapie, Psychosomatik, Medizinische Psychologie, 47, 58–63.
Schauenburg, H. (2000). Zum Verhältnis von Bindungsdiagnostik und psy- Thomasius, R., Weiler, D., Sack, P.-M., Schindler, A., Gemeinhardt, B.,
chodynamischer Diagnostik [The relation between attachment diagnosis and Schuhbert, C., & Küstner, U. (2001). Validität der Operationalisierten Psy-
psychodynamic diagnosis]. In W. Schneider & H. J. Freyberger (Eds.), Was chodynamischen Diagnostik (OPD) bei familientherapeutisch behandelten
leistet die OPD? Empirische Befunde und klinische Erfahrungen mit der Drogenabhängigen im adoleszenten und jungen Erwachsenenalter [Validity
Operationalisierten Psychodynamischen Diagnostik (pp. 196–217). Bern, of Operationalized Psychodynamic Diagnostics (OPD) in the field of family
Switzerland: Huber. therapy with adolescent and young adult drug addicts]. Psychotherapie, Psy-
Schauenburg, H., & Grande, T. (2011). Interview measures of interpersonal chosomatik, Medizinische Psychologie, 51, 365–372. doi:10.1055/s-2001-
functioning and quality of object relations. In L. M. Horowitz & S. Strack 16896
(Eds.), Handbook of interpersonal psychology: Theory, research, assessment, Tyrer, P., Crawford, M., Mulder, R., Blashfield, R., Farnam, A., Fossati, A.,
therapeutic interventions (pp. 343–358). Hoboken, NJ: Wiley. . . . Reed, G. M. (2011). The rationale for the reclassification of personality
Schneider, G., Lange, C., & Heuft, G. (2002). Operationalized Psychodynamic disorder in the 11th revision of the International Classification of Diseases
Diagnostics and differential therapy indication in routine diagnostics at a (ICD–11). Personality and Mental Health, 5, 246–259. doi:10.1002/pmh.190
psychosomatic outpatient department. Psychotherapy Research, 12, 159–178. Uzdawinis, D., Edel, M. A., Özgürdal, S., von Haebler, D., Hauser, M., Witthaus,
doi:10.1093/ptr/12.2.159 H., . . . Juckel, G. (2010). Operationalisierte Psychodynamische Diagnostik
Schneider, G., Mendler, T., Heuft, G., & Burgmer, M. (2008). Der Körper in der (OPD) bei Patienten im schizophrenen Prodromalstadium—Eine explorative
Konflikt- und Strukturdiagnostik der Operationalisierten Psychodynamischen Studie [Operationalized psychodynamic diagnostics (OPD) in patients in
Diagnostik—Bezug zu Körperkonzepten in der Selbstauskunft [The body in a prodromal state of schizophrenia—An explorative study]. Zeitschrift für
Operationalized Psychodynamic Diagnostics (OPD)— Its representation on Psychosomatische Medizin und Psychotherapie, 56, 150–162.
the axes “Conflicts” and “Structure” and correlations to self-assessment]. Wallerstein, R. S. (1991). Assessment of structural change in psychoanalytic
Zeitschrift für Psychosomatische Medizin und Psychotherapie, 54, 132–149. therapy and research. Journal of the American Psychoanalytic Association,
Schneider, W., Buchheim, P., Cierpka, M., Dahlbender, R., Freyberger, H. J., 36(Suppl.), 241–261.
Grande, T., . . . Schüßler, G. (2002). Operationalized Psychodynamic Diag- Weinryb, R. M., & Rössel, R. J. (1991). Karolinska Psychodynamic
nostics (OPD): A new diagnostic approach in psychodynamic psychotherapy. Profile—KAPP. Acta Psychiatrica Scandinavica, 83(Suppl. 363), 1–23.
In L. E. Beutler & M. Malik (Eds.), Rethinking the DSM: Psychological per- doi:10.1111/j.1600-0447.1991.tb10573.x
spectives (pp. 177–201). Washington, DC: American Psychological Associ- Westen, D. (1997). Divergences between clinical and research methods for
ation. doi:10.1037/10456-007 assessing personality disorders: Implications for research and the evolution
Shedler, J., Beck, A., Fonagy, P., Gabbard, G. O., Gunderson, J., Kernberg, of Axis II. American Journal of Psychiatry, 154, 895–903.
O., . . . Westen, D. (2010). Personality disorders in DSM–5. The American Westen, D., Barends, A., Leigh, J., Mendel, M., & Silbert, D. (1990). Social
Journal of Psychiatry, 167, 1026–1028. doi:10.1176/appi.ajp.2010.10050746 Cognition and Object Relations Scales (SCORS). Unpublished manuscript,
Skodol, A. E. (2012). Personality disorders in DSM–5. Annual Review of Clinical Department of Psychology, University of Michigan, Ann Arbor, MI.
Psychology, 8, 317–344. doi: 10.1146/annurev-clinpsy-032511-143131 Westen, D., Gabbard, G. O., & Blagov, P. (2006). Back to the future. Personality
Skodol, A. E., Bender, D. S., Morey, L. C., Clark, L. A., Oldham, J. M., structure as a context for psychopathology. In R. F. Krueger & J. L. Tack-
Alarcon, R. D., . . . Siever, L. J. (2011). Personality disorder types ett (Eds.), Personality and psychopathology (pp. 335–384). New York, NY:
proposed for DSM–5. Journal of Personality Disorder, 25, 136–169. Guilford.
doi:10.1521/pedi.2011.25.2.136 Westen, D., & Shedler, J. (1999). Revising and assessing Axis II, part I: De-
Skodol, A. E., Clark, L. A., Bender, D. S., Krueger, R. F., Morey, L. C., veloping a clinically and empirically valid assessment method. American
Verheul, R., . . . Oldham, J. M. (2011). Proposed changes in personality and Journal of Psychiatry, 156, 258–272.
personality disorder assessment and diagnosis for DSM–5 Part I: Description Widiger, T. A. (2011). A shaky future for personality disorders. Personal-
and rationale. Personality Disorders: Theory, Research, and Treatment, 2, ity Disorders: Theory, Research, and Treatment, 2, 54–67. doi:10.1037/
4–22. doi:10.1037/a0021891 a0021855
Spitzer, C., Michels-Lucht, F., Siebel, U., & Freyberger, H. J. (2002a). Die Widiger, T. A., & Samuel, D. B. (2005). Evidence-based assessment of person-
Strukturachse der operationalisierten psychodynamischen Diagnostik (OPD): ality disorders. Psychological Assessment, 17, 278–287. doi:10.1037/1040-
Zusammenhänge mit soziodemographischen, klinischen und psychopathol- 3590.17.3.278
ogischen Merkmalen sowie kategorialen Diagnosen [The axis “structure” Widiger, T. A., & Trull, T. J. (2007). Plate tectonics in the classification of per-
of the Operationalized Psychodynamic Diagnostics (OPD): Its relationship sonality disorder: Shifting to a dimensional model. American Psychologist,
with sociodemographic, clinical and psychopathological features as well as 62, 71–83. doi:10.1037/0003-066X.62.2.71
categorical diagnoses]. Psychotherapie, Psychosomatik, Medizinische Psy- World Health Organization. (1992). ICD–10: The ICD–10 classification of men-
chologie, 52, 392–397. doi:10.1055/s-2002-34290 tal and behavioural disorders: Clinical descriptions and diagnostic guide-
Spitzer, C., Michels-Lucht, F., Siebel, U., & Freyberger, H. J. (2002b). Zur lines. Geneva, Switzerland: Author.
Konstruktvalidität der Strukturachse der Operationalisierten Psychodynamis- Zimmerman, M., Rothschild, L., & Chelminski, I. (2005). The prevalence of
chen Diagnostik [On the validity of the axis “structure” of operationalized DSM–IV personality disorders in psychiatric outpatients. The American Jour-
psychodynamic diagnostics]. Zeitschrift für Psychosomatische Medizin und nal of Psychiatry, 162, 1911–1918. doi:10.1176/appi.ajp.162.10.1911
Psychotherapie, 48, 299–312. Zimmermann, J., Ehrenthal, J. C., Hörz, S., Rentrop, M., Rost, R., Schauenburg,
Spitzer, C., Michels-Lucht, F., Siebel, U., & Freyberger, H. J. (2004). H., . . . Cierpka, M. (2010). Neue Validierungsstudien zur Operationalisierten
Zum Zusammenhang zwischen OPD-Merkmalen der Persönlichkeitsstruk- Psychodynamischen Diagnostik (OPD–2)) [New validation studies on Opera-
tur und symptombezogenen sowie interpersonalen Behandlungsergebnissen tionalized Psychodynamic Diagnosis (OPD–2)]. Psychotherapeut, 55, 69–73.
stationärer Psychotherapie [The relationship between OPD features of person- doi:10.1007/s00278-009-0717-z
Copyright of Journal of Personality Assessment is the property of Taylor & Francis Ltd and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.